Healthcare Provider Details

I. General information

NPI: 1912981044
Provider Name (Legal Business Name): MODENA FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 ROUTE 32 SUITE 4
MODENA NY
12548
US

IV. Provider business mailing address

2044 ROUTE 32 SUITE 4
MODENA NY
12548
US

V. Phone/Fax

Practice location:
  • Phone: 845-883-5176
  • Fax: 845-883-5177
Mailing address:
  • Phone: 845-883-5176
  • Fax: 845-883-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number158508
License Number StateNY

VIII. Authorized Official

Name: DR. FRANCIS C MAYLE III
Title or Position: DOCTOR/OWNER
Credential: MD
Phone: 845-883-5176